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Lessons Learned Overview Mission Success First: Lessons Learned Overview Thermal and Fluids Analysis Workshop TFAWS August 6, 2014 Cleveland, Ohio Joe Nieberding Larry Ross 1 One Strike And You’re Out 2 ' Mission Success First: Lessons Learned Overview Thermal and Fluids Analysis Workshop TFAWS August 6, 2014 Cleveland, Ohio Joe Nieberding Larry Ross 3 “Mission Success First: Lessons Learned” Class Synopsis What went wrong? How did it happen? Could it happen again? How can we avoid repeating the mistakes of the past? No one knows like the people who were there, and have the scars to prove it from personal involvement in space mission failures. The majority of aerospace mishaps can be traced to easily recognized, preventable root causes resulting from a lack of quality somewhere in the system. Most missions are lost to human error, not rocket science. Examining and understanding these causes for more than forty actual aerospace mission failures is critical to helping today’s designers of any highly complex systems, aerospace or otherwise, identify system specific lessons that must be learned. These lessons are not unique to programs or time. They apply across multiple aerospace and non-aerospace endeavors. The same mistakes are being made today that were made fifty years ago. Implementing specific strategies and project “Rules of Practice” early in a program is the best means of prevention. Recognizing why the lessons of the past were not learned is also a critically important step in solving the problem. The two day “Mission Success First: Lessons Learned”classis“wordsfromthe wise” aimed at further strengthening system quality standards by understanding why they broke down in the past, and what to do about it. This class is among NASA’s most highly acclaimed classes. The importance of the topic has been recognized by NASA and the United States Aerospace community through invitations to present this class more than sixty times in the United States over the past six years, as well as multiple times in Europe and Asia. Joe Nieberding Larry Ross President, AEA Chief Executive Officer, AEA 4 ' Presenters Joe Nieberding: After earning a B.S in physics in 1966 and an M.S. in Engineering Science in 1972, Mr. Nieberding has acquired over 45 years of management and technical experience in the aerospace industry. In his early career, he was a launch team member on over 65 NASA Atlas/Centaur and Titan/Centaur launches at Kennedy Space Center. He is a widely recognized expert in launch vehicles and advanced transportation architecture planning for space missions. Later, he led and participated in many independent program review teams for NASA Headquarters. Before retiring from NASA Glenn Research Center in 2000, under his direction the Advanced Space Analysis Office led all exploration advanced concept studies for Glenn, including transportation, propulsion, power, and communications systems for many advanced NASA mission applications. Since retirement, he has held numerous consulting positions for NASA and other government agencies. In addition, Mr. Nieberding is co-founder and President of Aerospace Engineering Associates, and co-author and presenter of a highly acclaimed class titled “Mission Success First: Lessons Learned”. He is the father of four children and a husband of 47 years. 5 ' Presenters (concluded) Larry Ross: Mr. Ross has been a technical and management contributor in the aerospace industry for over forty eight years after having received a BS in electrical engineering from Manhattan College, Riverdale, New York City. His thirty-two year career at the NASA Lewis Research Center, now NASA Glenn, culminated in his assignment as Center Director from 1990-1994. Prior to that assignment he held the positions of Deputy Center Director, Director of Space, and Director of Launch Vehicles. Earlier in his career, he held various positions associated with engineering and program management of the Atlas/Centaur and Titan/Centaur Programs. He was chairman of the Delta 178 Failure Review Board in 1986. Mr. Ross retired from NASA in 1995, and since that time has served as a senior consultant to NASA and other Government agencies, as well as to the commercial aerospace Industry. Mr. Ross is co-founder and CEO of Aerospace Engineering Associates. He is the father of four children and a husband of forty eight years. 6 ' Preface • It’s vital for any enterprise to make mission success an overriding imperative – Failure can mean loss of the enterprise! – Second chance outcomes (if any) depend on successfully learning the lessons of the first attempt failure • Since Sputnik, NASA and the worldwide space community has a success rate of about 90% – Increased to about 95% over the last 25 years – But even a 5% failure rate is unacceptable and can be improved • An examination of space mission mishaps finds human error to be a dominant factor: – Its root causes are not unique to aerospace or to time – The same root causes are a threat in any endeavor • We analyze a representative sample of 43 cases to develop specific actions that would have defeated the human error involved – These “Rules of Practice” address systemic root causes and have applicability far beyond the specific cases from which they are derived – And far beyond the aerospace business These “Rules” emerge from “lessons learned the hard way” and will greatly help achieve Mission Success First! 7 ' Origin and Purpose of This Presentation • Began as effort to prepare Ares I (now cancelled) Non-Advocate Review Team – One hour presentation – much data compiled but unused – Later expanded to one and then two day presentation for wider audience • Purpose: to assist space system developers – Increase awareness of past mishaps and root causes – Help a new generation avoid the same pitfalls • Includes broad lessons learned – Multiple programs – Overarching fundamental lessons (generic) – Many specific examples of mishaps or mission failures • Observation: “root” causes not unique to times/programs – While some cases are from long ago, the relevance of the lessons is undiminished – Will be threats in any future development • Includes references for all resource information – Websites, failure reports, interviews, and subject matter experts • The “lessons” (yellow background charts) were either: – Developed independently by AEA based on analysis of the resource information, or – Extracted from the resource information It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. Mark Twain 8 ' Slide Box Color Key Title Text Slide for presentation Lesson(s) Learned (Supplementary Detail ) Slide not for presentation or (supplementary detail only) Additional Lessons Detailed Text Learned 9 ' Outline DAY 1 • Introduction Milan Cathedral Tay Rail Bridge • Historic Failures Hyatt Regency Hotel Tacoma Narrows Bridge • Space Mission Record of Success (Abbreviated) R-16 ICBM Explosion • Management Practices (Abbreviated) – Space Shuttle Solid Rocket Booster Project • What worked and what didn’t – Stephenson Report • The Culture of Testing (Abbreviated) • Lessons from Past Missions – Screening Out Design Errors Galileo; STS-51/TOS/ACTS; WIRE – Screening Out Procedural Errors AC-21; TC-1; TC-6; GPS IIR-3; NOAA N Prime – Impact of Weak Testing Practices Hubble; MPL; Genesis – Systems Engineering Lapses F-1; Skylab; X-43A; CONTOUR – Software Mishaps MCO, MGS – Flawed Processes Apollo 13 Explosion; AC-43 – Information Flow Breakdown B-2A; AA 191 – Component Failure AC-24 10 ' Outline (cont’d) DAY 2 • Lessons from Past Missions (cont’d) – Experienced Teams make Mistakes AC-67; Apollo 1; AC-62; TK 1951 – Normalizing Deviance Challenger; Apollo 13 POGO; Columbia – Missed Advanced Warnings Launch Availability; AC-33; Disneyland Monorail; Titan IVB-32/Milstar & AC-45 – Perils of Heritage Systems AC-5; Ariane 501 – Sabotage MDCA Microgravity Experiment – Management Factors Have Lost Missions N-1; MO; Helios; AA 96; TK 981 • Summary of Causes for the Past Mission Failures (Abbreviated) • The “Chain of Errors” Concept – The “Gimli Glider” – Loss of the X-31 • Two Lessons from a Different Perspective – From Space Station Freedom to the International Space Station – Flawed Failure Investigation of Atlas/Centaur 70 11 ' Outline (concluded) DAY 2 (concluded) • Common Cause Failures • The Human Element • Applying the Lessons: “Rules of Practice” • Conclusions • Appendix A: Presentation History to Date • Appendix B: Glossary of Terms • Appendix C: Case History Information Sources 12 ' Historic Failures Case Event The Milan Cathedral Wall collapse The Tay Rail Bridge Bridge collapse – 75 fatalities Kansas City Hyatt Regency Skyway Skyway collapse – 114 fatalities Tacoma Narrows Bridge Bridge collapse Russian R-16 ICBM Pad explosion - >120 fatalities 13 ' Historical Perspective: Prominent Failures from Across the Spectrum of Engineering Endeavors (cont’d) Tacoma Narrows Bridge Puget Sound Washington Opened 7/1/1940 Destroyed 11/7/1940 * From Original Drawings Plate Girder Typical Video 14 ' Space Mission Record of Success Sources: 1. http://www.sciencepresse.qc.ca/clafleur/Spacecrafts-index.html 2. http:www.starsem.com/soyuz/log.htm 3. http://en.wikipedia.org/wiki/atlas_V 4. FAA, Commercial Space Transportation, Year in Review, 2009, 2010, and 2011 5. http://www.ulalaunch.com/site/default.shtml 6. http://www.arianespace.com/launch-services- soyuz/Soyuz-Users-Manual-March-2012.pdf 15 ' Total Number of Spacecraft
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